The Hospitalist

SAN ANTONIO – Chronic liver disease increased mortality risk by up to about 80% in patients with pneumonia, according to an investigator who presented results of a large retrospective analysis.

Andrew Bowser/MDedge News

Liver disease increased the risk of intubation by 39% and increased length of stay by 1 day in the study, presented at the annual meeting of the American College of Chest Physicians.

These findings have implications for clinicians and the scoring systems they use to evaluate patients with pneumonia, according to investigator Zin Mar Htun, MD, internal medicine resident at Louis A. Weiss Memorial Hospital and Presence Saint Joseph Hospital, Chicago.

“We should recognize the importance of chronic liver disease as an independent risk factor for worse outcomes in pneumonia, regardless of the clinical findings or other coexisting comorbidities,” Dr. Htun said in a podium presentation.

Traditional scoring systems for evaluating pneumonia severity do not incorporate hepatic function status, she said.

“We need to come up with a better scoring system that recognizes comorbidities better than the Patient Safety Indicator scoring,” she told attendees at the meeting.

In their study, Dr. Htun and coinvestigator Muhammad Gul, MD, used the 2014 Nationwide Inpatient Sample database to look at pneumonia patients with or without a liver disease diagnosis.

Intubation was done in 14.2% of pneumonia patients with chronic liver disease present, compared with 10.6% of patients with no chronic liver disease (odds ratio [OR], 1.39; 95% confidence interval, 1.30-1.48) in one of their analyses, which included 17,528 pneumonia patients with a liver disease diagnosis and 17,528 pneumonia patients with no such diagnosis, propensity score-matched for age, gender, and Charlson comorbidities.

Length of stay was 8.76 and 7.83 days, respectively, for pneumonia patients with and without chronic liver disease (P less than .001), the propensity score-matched analysis further showed. In-hospital mortality was 10.5% and 6.9% for the liver disease and no liver disease groups in this analysis (OR, 1.57; 95% CI, 1.46-1.70).

In a regression analysis looking at 1.5 million pneumonia patients, of whom about 51,000 had chronic liver disease, the odds ratio for mortality was 1.82 (95% CI, 1.76-1.88; P less than .001), Dr. Htun further reported.

The pathogens causing pneumonia in patients with chronic liver disease were about the same as those in other hospitalized patients, she said in her presentation.

These are “compelling” results that suggest liver disease should considered as a factor in the development of future pneumonia scoring systems, according to Zachary Q. Morris, MD, of Henry Ford Hospital.

Creators of scoring systems may err on the side of making them “simplistic” so they are accessible and easy to analyze, Dr. Morris said in an interview.

“There comes a point in time that maybe you do need to have another layer of complexity to it,” added Dr. Morris, who moderated the original research session where Dr. Htun presented her results.

Both Dr. Htun and Dr. Gul reported that they had no relationships relevant to their study.

SOURCE: Htun ZM, et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.862.

SAN ANTONIO – Chronic liver disease increased mortality risk by up to about 80% in patients with pneumonia, according to an investigator who presented results of a large retrospective analysis.

Andrew Bowser/MDedge News

Liver disease increased the risk of intubation by 39% and increased length of stay by 1 day in the study, presented at the annual meeting of the American College of Chest Physicians.

These findings have implications for clinicians and the scoring systems they use to evaluate patients with pneumonia, according to investigator Zin Mar Htun, MD, internal medicine resident at Louis A. Weiss Memorial Hospital and Presence Saint Joseph Hospital, Chicago.

“We should recognize the importance of chronic liver disease as an independent risk factor for worse outcomes in pneumonia, regardless of the clinical findings or other coexisting comorbidities,” Dr. Htun said in a podium presentation.

Traditional scoring systems for evaluating pneumonia severity do not incorporate hepatic function status, she said.

“We need to come up with a better scoring system that recognizes comorbidities better than the Patient Safety Indicator scoring,” she told attendees at the meeting.

In their study, Dr. Htun and coinvestigator Muhammad Gul, MD, used the 2014 Nationwide Inpatient Sample database to look at pneumonia patients with or without a liver disease diagnosis.

Intubation was done in 14.2% of pneumonia patients with chronic liver disease present, compared with 10.6% of patients with no chronic liver disease (odds ratio [OR], 1.39; 95% confidence interval, 1.30-1.48) in one of their analyses, which included 17,528 pneumonia patients with a liver disease diagnosis and 17,528 pneumonia patients with no such diagnosis, propensity score-matched for age, gender, and Charlson comorbidities.

Length of stay was 8.76 and 7.83 days, respectively, for pneumonia patients with and without chronic liver disease (P less than .001), the propensity score-matched analysis further showed. In-hospital mortality was 10.5% and 6.9% for the liver disease and no liver disease groups in this analysis (OR, 1.57; 95% CI, 1.46-1.70).

In a regression analysis looking at 1.5 million pneumonia patients, of whom about 51,000 had chronic liver disease, the odds ratio for mortality was 1.82 (95% CI, 1.76-1.88; P less than .001), Dr. Htun further reported.

The pathogens causing pneumonia in patients with chronic liver disease were about the same as those in other hospitalized patients, she said in her presentation.

These are “compelling” results that suggest liver disease should considered as a factor in the development of future pneumonia scoring systems, according to Zachary Q. Morris, MD, of Henry Ford Hospital.

Creators of scoring systems may err on the side of making them “simplistic” so they are accessible and easy to analyze, Dr. Morris said in an interview.

“There comes a point in time that maybe you do need to have another layer of complexity to it,” added Dr. Morris, who moderated the original research session where Dr. Htun presented her results.

Both Dr. Htun and Dr. Gul reported that they had no relationships relevant to their study.

SOURCE: Htun ZM, et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.862.

SAN ANTONIO – Chronic liver disease increased mortality risk by up to about 80% in patients with pneumonia, according to an investigator who presented results of a large retrospective analysis.

Andrew Bowser/MDedge News

Liver disease increased the risk of intubation by 39% and increased length of stay by 1 day in the study, presented at the annual meeting of the American College of Chest Physicians.

These findings have implications for clinicians and the scoring systems they use to evaluate patients with pneumonia, according to investigator Zin Mar Htun, MD, internal medicine resident at Louis A. Weiss Memorial Hospital and Presence Saint Joseph Hospital, Chicago.

“We should recognize the importance of chronic liver disease as an independent risk factor for worse outcomes in pneumonia, regardless of the clinical findings or other coexisting comorbidities,” Dr. Htun said in a podium presentation.

Traditional scoring systems for evaluating pneumonia severity do not incorporate hepatic function status, she said.

“We need to come up with a better scoring system that recognizes comorbidities better than the Patient Safety Indicator scoring,” she told attendees at the meeting.

In their study, Dr. Htun and coinvestigator Muhammad Gul, MD, used the 2014 Nationwide Inpatient Sample database to look at pneumonia patients with or without a liver disease diagnosis.

Intubation was done in 14.2% of pneumonia patients with chronic liver disease present, compared with 10.6% of patients with no chronic liver disease (odds ratio [OR], 1.39; 95% confidence interval, 1.30-1.48) in one of their analyses, which included 17,528 pneumonia patients with a liver disease diagnosis and 17,528 pneumonia patients with no such diagnosis, propensity score-matched for age, gender, and Charlson comorbidities.

Length of stay was 8.76 and 7.83 days, respectively, for pneumonia patients with and without chronic liver disease (P less than .001), the propensity score-matched analysis further showed. In-hospital mortality was 10.5% and 6.9% for the liver disease and no liver disease groups in this analysis (OR, 1.57; 95% CI, 1.46-1.70).

In a regression analysis looking at 1.5 million pneumonia patients, of whom about 51,000 had chronic liver disease, the odds ratio for mortality was 1.82 (95% CI, 1.76-1.88; P less than .001), Dr. Htun further reported.

The pathogens causing pneumonia in patients with chronic liver disease were about the same as those in other hospitalized patients, she said in her presentation.

These are “compelling” results that suggest liver disease should considered as a factor in the development of future pneumonia scoring systems, according to Zachary Q. Morris, MD, of Henry Ford Hospital.

Creators of scoring systems may err on the side of making them “simplistic” so they are accessible and easy to analyze, Dr. Morris said in an interview.

“There comes a point in time that maybe you do need to have another layer of complexity to it,” added Dr. Morris, who moderated the original research session where Dr. Htun presented her results.

Both Dr. Htun and Dr. Gul reported that they had no relationships relevant to their study.

SOURCE: Htun ZM, et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.862.

More states are expanding their telehealth policies to reach patients, and pulling back on rigid in-person requirements.   

Several state Medicaid programs now explicitly allow the home to serve as an originating site for telehealth, with 10 states – Delaware, Colorado, Maryland, Michigan, Minnesota, Montana, New York, Texas, Washington, and Wyoming – adding the home as an approved site since 2016.

In addition, 16 jurisdictions now allow schools to serve as originating sites for telehealth, although some have restrictions about when the sites are acceptable, said Mei Kwong, an attorney and executive director for the Center for Connected Health Policy and the author of the center’s Spring 2018 report on telehealth trends.   

At the same time, nearly all states have now dropped Medicaid restrictions that limited reimbursable telehealth services to rural or underserved areas. Colorado, Idaho, Nebraska, New Hampshire, Nevada, and Missouri are the most recent states to remove such geographic restrictions.

“[The expanded locations are] extremely helpful in providing greater access for patients to needed services,” Ms. Kwong said in an interview. “For example, a person who has difficulty leaving his or her home for a physical or other reason, they can get care, [or] a child having a rough time in school, can seek out a mental health counselor while at school.”
 

More telehealth providers

In addition to expanding teleheath sites, states are increasing acceptance for telehealth providers beyond physicians. Most recently, New Jersey enacted a broad telemedicine law that includes doctors, nurses, psychologists, social workers, physician assistants, counselors, respiratory therapists, speech pathologists, and optometrists, among others. The New Jersey law addresses telemedicine practice standards, prescribing, patient consent, privacy, and other requirements for providers.

In addition, more states are carving out telehealth regulations. Since 2016, 11 states have revised or adopted new scope of practice restrictions for counselors providing telemedicine, according to a state telehealth analysis published in July 2018 by law firm Epstein, Becker, Green.

Arkansas, Idaho, Maine, New Jersey, and Rhode Island recently imposed regulations for the practice of telepsychology. In addition, seven states have new or revised scope of practice restrictions for advanced practice registered nurses (APRN) providing telehealth services, while eight states have new licensing requirements specific to telehealth practice by APRNs, according to the Epstein analysis.

A telehealth compact that would allow APRNs to practice nursing via telemedicine across state lines is also in the works. Similar to the physician Interstate Medical Licensure Compact, the APRN Compact would establish an interstate commission and guidelines for uniform licensing requirements and criminal background checks. The compact will become effective when 10 states enact the compact legislation. So far, three states – Wyoming, North Dakota, and Idaho – have enacted the model legislation.

Another telemedicine compact for psychologists is getting ready to launch. In August, Illinois became the seventh state to join the Psychology Interjurisdictional Compact (PSYPACT). The pact requires seven states to enact compact legislation to become effective, however Illinois law does not go into effect until 2020.

The developments highlight the rise in more mid- and lower-level providers practicing telemedicine, said Anjali B. Dooley, an attorney and chief legal and compliance officer for Forefront Telecare, a telehealth platform for behavioral health services. While the increase allows greater care access, the expansion also poses scope of practice challenges, she notes.

“Increasing scope of practice extensions also increases risk if physician extenders are not trained properly in telehealth technology use and protocols,” Ms. Dooley said in an interview. “Providers and provider extenders need to be educated and learned in human factors such as communication, empathy, and etiquette.”

A greater number of nonphysician telemedicine providers is beneficial as long as the providers are adhering to appropriate standards of care and consulting with supervising physicians when necessary, adds Jean R. Sumner, MD, dean of the School of Medicine at Mercer University in Macon, Georgia, and a telemedicine internist.  

“The standard should always be equal to an in-person visit,” she said in an interview. “The patient has a right to know who is seeing them, too, to understand [their credentials]. They need to know the person on the telehealth unit is qualified to provide the care.”
 

Responding to the opioid crisis

The need for increased access to mental health care is a primary driver behind state efforts to expand the pool of telemedicine providers, adds Amy Lerman, an attorney at Epstein, Becker, Green and lead author of her firm’s report.

“The reason it is important for states to continue expanding the scope of health professionals, other than physicians, who can provide behavioral health telemedicine services, is not only to address an overall nationwide shortage of behavioral health providers, but also to expand access to behavioral health services because a wider range of providers are equipped to provide these services,” she said in an interview.

In the same vein, more states are using telehealth to address the opioid crisis, according to both the Epstein report and the Center for Connected Health Policy analysis.

In September, California enacted a law that would allow Medicaid reimbursement for certified substance use disorder counselors who provide treatment via telehealth. In August, Illinois approved a similar law that mandates reimbursement for behavioral and mental health experts who treat Medicaid patients through telehealth technologies.

The laws come after a June 2018 letter from the Centers for Medicare & Medicaid Services that encouraged states to utilize health technology efforts to address the opioid crisis, including through telemedicine and telepsychiatry, said Daniel Kim, an attorney with Epstein, Becker, Green and a coauthor of his firm’s report.

At the same time, a number of states have expanded their controlled substance laws to allow remote prescribing through telehealth for the treatment of psychiatric or substance use disorders. Connecticut’s law, for instance, allows providers to prescribe Schedule I-III controlled substances through telehealth platforms, while banning opioid prescribing. In Indiana, 2017 legislation expanded the types of controlled medications that providers can prescribe through telehealth platforms, primarily drugs used to treat or manage opioid dependence. The states join an increasing number that have enacted laws allowing the remote prescribing of controlled substances, including Delaware, Florida, Indiana, Michigan, New Hampshire, Ohio, and West Virginia.

The new laws will enhance the availability of behavioral health services, while allowing more treatment flexibility and privacy for patients, said Ms. Dooley.

“Treatment in one’s own environment where the addiction takes place is often more effective,” she said. People with addiction disorders “can also receive treatment without having to drive long distances.”
 

The disappearing in-person requirement

As states define their telehealth policies, they are fading out a once-prevalent requirement – the in-person visit. There is no longer a single state that requires physicians to meet with patients in-person before providing telemedicine services, according to the Epstein report.

States realized that requiring in-person visits before doctors can provide telemedicine creates a barrier to care, said Mr. Kim. A move to eliminate the requirement in Texas influenced other states in phasing out the common regulation. In the widely publicized Teladoc case, the national telemedicine company sued the Texas Medical Board in 2011 over its rule requiring Texas physicians to conduct a face-to-face evaluation before treating a patient via telemedicine. The legal battle continued for years, until Teladoc voluntarily dropped its lawsuit in 2017 after Texas adopted a new law that allowed doctors to treat first-time patients through telemedicine.

“The medical board [understood] that the in-person requirement wasn’t really a benefit to patients,” Mr. Kim said in an interview. “Once they changed it, a lot of other states have recognized the same and have moved toward getting rid of the requirement.”

In some states, midlevel providers still must see patients face-to-face before providing telehealth care. Arkansas for instance, requires that psychologists, counselors, and APRNs conduct an in-person exam before rendering telehealth. Professional boards in Colorado and Massachusetts recommend a face-to-face visit by midlevel providers as a best practice.
 

Reimbursement growing, but restrictions remain

Forty-nine states and the District of Columbia reimburse for some form of telehealth, mainly live video services. At least 20 states now pay providers for remote payment monitoring (RPM), according to the Center for Connected Health Policy report. The reimbursement is often restricted, however, to certain clinical conditions and/or rules that limit the type of monitoring device allowed. Colorado, for instance, only reimburses RPM for patients with congestive heart failure, chronic obstructive pulmonary disease, asthma, or diabetes and requires that the patient was hospitalized at least twice in the last 12 months for reasons associated with one of the conditions. Missouri has similar RPM criteria associated with hospitalizations, but allows for a greater number of conditions including pregnancy, stroke, and cancer.

Most states have yet to pay for store-and-forward services, technologies that enable the electronic transfer of photos, prerecorded videos, or documents. Only about 14 states reimburse for such technology, and many policies include limitations. California, for example, only reimburses for store-and-forward services in teledermatology, teledentistry, and teleophthalmology. Connecticut allows for store-and-forward payment between physicians through email. Missouri allows for store-and-forward services in orthopedics, dermatology, optometry, ophthalmology, and in cases of retinopathy, burn and wound care, dental services, and maternal-fetal ultrasounds.

Reimbursement for telehealth is still a challenge for many physicians, Dr. Sumner said. Part of the problem is the wide discrepancy in how telehealth is defined among states, she said. Some states only consider live or interactive two-way technology as telehealth, excluding services such as store-and-forward and RPM. Other states reimburse for certain technology-based services, but they do not consider them telehealth. Maryland’s Medicaid program for example, does not reimburse for store and forward under its telehealth policy. However, store and forward used in dermatology, radiology, and ophthalmology is reimbursed by Maryland under an alternate billing code, though not considered telehealth.

Establishing best practices in telehealth through careful evaluation and research would improve reimbursement, said S. David McSwain, MD, interim chief medical information officer at the Medical University of South Carolina, Charleston, and medical director for telehealth optimization.

“We can use that evidence to reduce the variation in telehealth payment policies across the states,” Dr. McSwain said in an interview. “By leveraging reimbursement models to promote best practices, we can encourage the spread of telehealth services that have the greatest impacts on patients, their families, and the health care system.”

More states are expanding their telehealth policies to reach patients, and pulling back on rigid in-person requirements.   

Several state Medicaid programs now explicitly allow the home to serve as an originating site for telehealth, with 10 states – Delaware, Colorado, Maryland, Michigan, Minnesota, Montana, New York, Texas, Washington, and Wyoming – adding the home as an approved site since 2016.

In addition, 16 jurisdictions now allow schools to serve as originating sites for telehealth, although some have restrictions about when the sites are acceptable, said Mei Kwong, an attorney and executive director for the Center for Connected Health Policy and the author of the center’s Spring 2018 report on telehealth trends.   

At the same time, nearly all states have now dropped Medicaid restrictions that limited reimbursable telehealth services to rural or underserved areas. Colorado, Idaho, Nebraska, New Hampshire, Nevada, and Missouri are the most recent states to remove such geographic restrictions.

“[The expanded locations are] extremely helpful in providing greater access for patients to needed services,” Ms. Kwong said in an interview. “For example, a person who has difficulty leaving his or her home for a physical or other reason, they can get care, [or] a child having a rough time in school, can seek out a mental health counselor while at school.”
 

More telehealth providers

In addition to expanding teleheath sites, states are increasing acceptance for telehealth providers beyond physicians. Most recently, New Jersey enacted a broad telemedicine law that includes doctors, nurses, psychologists, social workers, physician assistants, counselors, respiratory therapists, speech pathologists, and optometrists, among others. The New Jersey law addresses telemedicine practice standards, prescribing, patient consent, privacy, and other requirements for providers.

In addition, more states are carving out telehealth regulations. Since 2016, 11 states have revised or adopted new scope of practice restrictions for counselors providing telemedicine, according to a state telehealth analysis published in July 2018 by law firm Epstein, Becker, Green.

Arkansas, Idaho, Maine, New Jersey, and Rhode Island recently imposed regulations for the practice of telepsychology. In addition, seven states have new or revised scope of practice restrictions for advanced practice registered nurses (APRN) providing telehealth services, while eight states have new licensing requirements specific to telehealth practice by APRNs, according to the Epstein analysis.

A telehealth compact that would allow APRNs to practice nursing via telemedicine across state lines is also in the works. Similar to the physician Interstate Medical Licensure Compact, the APRN Compact would establish an interstate commission and guidelines for uniform licensing requirements and criminal background checks. The compact will become effective when 10 states enact the compact legislation. So far, three states – Wyoming, North Dakota, and Idaho – have enacted the model legislation.

Another telemedicine compact for psychologists is getting ready to launch. In August, Illinois became the seventh state to join the Psychology Interjurisdictional Compact (PSYPACT). The pact requires seven states to enact compact legislation to become effective, however Illinois law does not go into effect until 2020.

The developments highlight the rise in more mid- and lower-level providers practicing telemedicine, said Anjali B. Dooley, an attorney and chief legal and compliance officer for Forefront Telecare, a telehealth platform for behavioral health services. While the increase allows greater care access, the expansion also poses scope of practice challenges, she notes.

“Increasing scope of practice extensions also increases risk if physician extenders are not trained properly in telehealth technology use and protocols,” Ms. Dooley said in an interview. “Providers and provider extenders need to be educated and learned in human factors such as communication, empathy, and etiquette.”

A greater number of nonphysician telemedicine providers is beneficial as long as the providers are adhering to appropriate standards of care and consulting with supervising physicians when necessary, adds Jean R. Sumner, MD, dean of the School of Medicine at Mercer University in Macon, Georgia, and a telemedicine internist.  

“The standard should always be equal to an in-person visit,” she said in an interview. “The patient has a right to know who is seeing them, too, to understand [their credentials]. They need to know the person on the telehealth unit is qualified to provide the care.”
 

Responding to the opioid crisis

The need for increased access to mental health care is a primary driver behind state efforts to expand the pool of telemedicine providers, adds Amy Lerman, an attorney at Epstein, Becker, Green and lead author of her firm’s report.

“The reason it is important for states to continue expanding the scope of health professionals, other than physicians, who can provide behavioral health telemedicine services, is not only to address an overall nationwide shortage of behavioral health providers, but also to expand access to behavioral health services because a wider range of providers are equipped to provide these services,” she said in an interview.

In the same vein, more states are using telehealth to address the opioid crisis, according to both the Epstein report and the Center for Connected Health Policy analysis.

In September, California enacted a law that would allow Medicaid reimbursement for certified substance use disorder counselors who provide treatment via telehealth. In August, Illinois approved a similar law that mandates reimbursement for behavioral and mental health experts who treat Medicaid patients through telehealth technologies.

The laws come after a June 2018 letter from the Centers for Medicare & Medicaid Services that encouraged states to utilize health technology efforts to address the opioid crisis, including through telemedicine and telepsychiatry, said Daniel Kim, an attorney with Epstein, Becker, Green and a coauthor of his firm’s report.

At the same time, a number of states have expanded their controlled substance laws to allow remote prescribing through telehealth for the treatment of psychiatric or substance use disorders. Connecticut’s law, for instance, allows providers to prescribe Schedule I-III controlled substances through telehealth platforms, while banning opioid prescribing. In Indiana, 2017 legislation expanded the types of controlled medications that providers can prescribe through telehealth platforms, primarily drugs used to treat or manage opioid dependence. The states join an increasing number that have enacted laws allowing the remote prescribing of controlled substances, including Delaware, Florida, Indiana, Michigan, New Hampshire, Ohio, and West Virginia.

The new laws will enhance the availability of behavioral health services, while allowing more treatment flexibility and privacy for patients, said Ms. Dooley.

“Treatment in one’s own environment where the addiction takes place is often more effective,” she said. People with addiction disorders “can also receive treatment without having to drive long distances.”
 

The disappearing in-person requirement

As states define their telehealth policies, they are fading out a once-prevalent requirement – the in-person visit. There is no longer a single state that requires physicians to meet with patients in-person before providing telemedicine services, according to the Epstein report.

States realized that requiring in-person visits before doctors can provide telemedicine creates a barrier to care, said Mr. Kim. A move to eliminate the requirement in Texas influenced other states in phasing out the common regulation. In the widely publicized Teladoc case, the national telemedicine company sued the Texas Medical Board in 2011 over its rule requiring Texas physicians to conduct a face-to-face evaluation before treating a patient via telemedicine. The legal battle continued for years, until Teladoc voluntarily dropped its lawsuit in 2017 after Texas adopted a new law that allowed doctors to treat first-time patients through telemedicine.

“The medical board [understood] that the in-person requirement wasn’t really a benefit to patients,” Mr. Kim said in an interview. “Once they changed it, a lot of other states have recognized the same and have moved toward getting rid of the requirement.”

In some states, midlevel providers still must see patients face-to-face before providing telehealth care. Arkansas for instance, requires that psychologists, counselors, and APRNs conduct an in-person exam before rendering telehealth. Professional boards in Colorado and Massachusetts recommend a face-to-face visit by midlevel providers as a best practice.
 

Reimbursement growing, but restrictions remain

Forty-nine states and the District of Columbia reimburse for some form of telehealth, mainly live video services. At least 20 states now pay providers for remote payment monitoring (RPM), according to the Center for Connected Health Policy report. The reimbursement is often restricted, however, to certain clinical conditions and/or rules that limit the type of monitoring device allowed. Colorado, for instance, only reimburses RPM for patients with congestive heart failure, chronic obstructive pulmonary disease, asthma, or diabetes and requires that the patient was hospitalized at least twice in the last 12 months for reasons associated with one of the conditions. Missouri has similar RPM criteria associated with hospitalizations, but allows for a greater number of conditions including pregnancy, stroke, and cancer.

Most states have yet to pay for store-and-forward services, technologies that enable the electronic transfer of photos, prerecorded videos, or documents. Only about 14 states reimburse for such technology, and many policies include limitations. California, for example, only reimburses for store-and-forward services in teledermatology, teledentistry, and teleophthalmology. Connecticut allows for store-and-forward payment between physicians through email. Missouri allows for store-and-forward services in orthopedics, dermatology, optometry, ophthalmology, and in cases of retinopathy, burn and wound care, dental services, and maternal-fetal ultrasounds.

Reimbursement for telehealth is still a challenge for many physicians, Dr. Sumner said. Part of the problem is the wide discrepancy in how telehealth is defined among states, she said. Some states only consider live or interactive two-way technology as telehealth, excluding services such as store-and-forward and RPM. Other states reimburse for certain technology-based services, but they do not consider them telehealth. Maryland’s Medicaid program for example, does not reimburse for store and forward under its telehealth policy. However, store and forward used in dermatology, radiology, and ophthalmology is reimbursed by Maryland under an alternate billing code, though not considered telehealth.

Establishing best practices in telehealth through careful evaluation and research would improve reimbursement, said S. David McSwain, MD, interim chief medical information officer at the Medical University of South Carolina, Charleston, and medical director for telehealth optimization.

“We can use that evidence to reduce the variation in telehealth payment policies across the states,” Dr. McSwain said in an interview. “By leveraging reimbursement models to promote best practices, we can encourage the spread of telehealth services that have the greatest impacts on patients, their families, and the health care system.”

More states are expanding their telehealth policies to reach patients, and pulling back on rigid in-person requirements.   

Several state Medicaid programs now explicitly allow the home to serve as an originating site for telehealth, with 10 states – Delaware, Colorado, Maryland, Michigan, Minnesota, Montana, New York, Texas, Washington, and Wyoming – adding the home as an approved site since 2016.

In addition, 16 jurisdictions now allow schools to serve as originating sites for telehealth, although some have restrictions about when the sites are acceptable, said Mei Kwong, an attorney and executive director for the Center for Connected Health Policy and the author of the center’s Spring 2018 report on telehealth trends.   

At the same time, nearly all states have now dropped Medicaid restrictions that limited reimbursable telehealth services to rural or underserved areas. Colorado, Idaho, Nebraska, New Hampshire, Nevada, and Missouri are the most recent states to remove such geographic restrictions.

“[The expanded locations are] extremely helpful in providing greater access for patients to needed services,” Ms. Kwong said in an interview. “For example, a person who has difficulty leaving his or her home for a physical or other reason, they can get care, [or] a child having a rough time in school, can seek out a mental health counselor while at school.”
 

More telehealth providers

In addition to expanding teleheath sites, states are increasing acceptance for telehealth providers beyond physicians. Most recently, New Jersey enacted a broad telemedicine law that includes doctors, nurses, psychologists, social workers, physician assistants, counselors, respiratory therapists, speech pathologists, and optometrists, among others. The New Jersey law addresses telemedicine practice standards, prescribing, patient consent, privacy, and other requirements for providers.

In addition, more states are carving out telehealth regulations. Since 2016, 11 states have revised or adopted new scope of practice restrictions for counselors providing telemedicine, according to a state telehealth analysis published in July 2018 by law firm Epstein, Becker, Green.

Arkansas, Idaho, Maine, New Jersey, and Rhode Island recently imposed regulations for the practice of telepsychology. In addition, seven states have new or revised scope of practice restrictions for advanced practice registered nurses (APRN) providing telehealth services, while eight states have new licensing requirements specific to telehealth practice by APRNs, according to the Epstein analysis.

A telehealth compact that would allow APRNs to practice nursing via telemedicine across state lines is also in the works. Similar to the physician Interstate Medical Licensure Compact, the APRN Compact would establish an interstate commission and guidelines for uniform licensing requirements and criminal background checks. The compact will become effective when 10 states enact the compact legislation. So far, three states – Wyoming, North Dakota, and Idaho – have enacted the model legislation.

Another telemedicine compact for psychologists is getting ready to launch. In August, Illinois became the seventh state to join the Psychology Interjurisdictional Compact (PSYPACT). The pact requires seven states to enact compact legislation to become effective, however Illinois law does not go into effect until 2020.

The developments highlight the rise in more mid- and lower-level providers practicing telemedicine, said Anjali B. Dooley, an attorney and chief legal and compliance officer for Forefront Telecare, a telehealth platform for behavioral health services. While the increase allows greater care access, the expansion also poses scope of practice challenges, she notes.

“Increasing scope of practice extensions also increases risk if physician extenders are not trained properly in telehealth technology use and protocols,” Ms. Dooley said in an interview. “Providers and provider extenders need to be educated and learned in human factors such as communication, empathy, and etiquette.”

A greater number of nonphysician telemedicine providers is beneficial as long as the providers are adhering to appropriate standards of care and consulting with supervising physicians when necessary, adds Jean R. Sumner, MD, dean of the School of Medicine at Mercer University in Macon, Georgia, and a telemedicine internist.  

“The standard should always be equal to an in-person visit,” she said in an interview. “The patient has a right to know who is seeing them, too, to understand [their credentials]. They need to know the person on the telehealth unit is qualified to provide the care.”
 

Responding to the opioid crisis

The need for increased access to mental health care is a primary driver behind state efforts to expand the pool of telemedicine providers, adds Amy Lerman, an attorney at Epstein, Becker, Green and lead author of her firm’s report.

“The reason it is important for states to continue expanding the scope of health professionals, other than physicians, who can provide behavioral health telemedicine services, is not only to address an overall nationwide shortage of behavioral health providers, but also to expand access to behavioral health services because a wider range of providers are equipped to provide these services,” she said in an interview.

In the same vein, more states are using telehealth to address the opioid crisis, according to both the Epstein report and the Center for Connected Health Policy analysis.

In September, California enacted a law that would allow Medicaid reimbursement for certified substance use disorder counselors who provide treatment via telehealth. In August, Illinois approved a similar law that mandates reimbursement for behavioral and mental health experts who treat Medicaid patients through telehealth technologies.

The laws come after a June 2018 letter from the Centers for Medicare & Medicaid Services that encouraged states to utilize health technology efforts to address the opioid crisis, including through telemedicine and telepsychiatry, said Daniel Kim, an attorney with Epstein, Becker, Green and a coauthor of his firm’s report.

At the same time, a number of states have expanded their controlled substance laws to allow remote prescribing through telehealth for the treatment of psychiatric or substance use disorders. Connecticut’s law, for instance, allows providers to prescribe Schedule I-III controlled substances through telehealth platforms, while banning opioid prescribing. In Indiana, 2017 legislation expanded the types of controlled medications that providers can prescribe through telehealth platforms, primarily drugs used to treat or manage opioid dependence. The states join an increasing number that have enacted laws allowing the remote prescribing of controlled substances, including Delaware, Florida, Indiana, Michigan, New Hampshire, Ohio, and West Virginia.

The new laws will enhance the availability of behavioral health services, while allowing more treatment flexibility and privacy for patients, said Ms. Dooley.

“Treatment in one’s own environment where the addiction takes place is often more effective,” she said. People with addiction disorders “can also receive treatment without having to drive long distances.”
 

The disappearing in-person requirement

As states define their telehealth policies, they are fading out a once-prevalent requirement – the in-person visit. There is no longer a single state that requires physicians to meet with patients in-person before providing telemedicine services, according to the Epstein report.

States realized that requiring in-person visits before doctors can provide telemedicine creates a barrier to care, said Mr. Kim. A move to eliminate the requirement in Texas influenced other states in phasing out the common regulation. In the widely publicized Teladoc case, the national telemedicine company sued the Texas Medical Board in 2011 over its rule requiring Texas physicians to conduct a face-to-face evaluation before treating a patient via telemedicine. The legal battle continued for years, until Teladoc voluntarily dropped its lawsuit in 2017 after Texas adopted a new law that allowed doctors to treat first-time patients through telemedicine.

“The medical board [understood] that the in-person requirement wasn’t really a benefit to patients,” Mr. Kim said in an interview. “Once they changed it, a lot of other states have recognized the same and have moved toward getting rid of the requirement.”

In some states, midlevel providers still must see patients face-to-face before providing telehealth care. Arkansas for instance, requires that psychologists, counselors, and APRNs conduct an in-person exam before rendering telehealth. Professional boards in Colorado and Massachusetts recommend a face-to-face visit by midlevel providers as a best practice.
 

Reimbursement growing, but restrictions remain

Forty-nine states and the District of Columbia reimburse for some form of telehealth, mainly live video services. At least 20 states now pay providers for remote payment monitoring (RPM), according to the Center for Connected Health Policy report. The reimbursement is often restricted, however, to certain clinical conditions and/or rules that limit the type of monitoring device allowed. Colorado, for instance, only reimburses RPM for patients with congestive heart failure, chronic obstructive pulmonary disease, asthma, or diabetes and requires that the patient was hospitalized at least twice in the last 12 months for reasons associated with one of the conditions. Missouri has similar RPM criteria associated with hospitalizations, but allows for a greater number of conditions including pregnancy, stroke, and cancer.

Most states have yet to pay for store-and-forward services, technologies that enable the electronic transfer of photos, prerecorded videos, or documents. Only about 14 states reimburse for such technology, and many policies include limitations. California, for example, only reimburses for store-and-forward services in teledermatology, teledentistry, and teleophthalmology. Connecticut allows for store-and-forward payment between physicians through email. Missouri allows for store-and-forward services in orthopedics, dermatology, optometry, ophthalmology, and in cases of retinopathy, burn and wound care, dental services, and maternal-fetal ultrasounds.

Reimbursement for telehealth is still a challenge for many physicians, Dr. Sumner said. Part of the problem is the wide discrepancy in how telehealth is defined among states, she said. Some states only consider live or interactive two-way technology as telehealth, excluding services such as store-and-forward and RPM. Other states reimburse for certain technology-based services, but they do not consider them telehealth. Maryland’s Medicaid program for example, does not reimburse for store and forward under its telehealth policy. However, store and forward used in dermatology, radiology, and ophthalmology is reimbursed by Maryland under an alternate billing code, though not considered telehealth.

Establishing best practices in telehealth through careful evaluation and research would improve reimbursement, said S. David McSwain, MD, interim chief medical information officer at the Medical University of South Carolina, Charleston, and medical director for telehealth optimization.

“We can use that evidence to reduce the variation in telehealth payment policies across the states,” Dr. McSwain said in an interview. “By leveraging reimbursement models to promote best practices, we can encourage the spread of telehealth services that have the greatest impacts on patients, their families, and the health care system.”

Clinical question: Can a procalcitonin (PCT)–guided strategy safely reduce antibiotic exposure in patients admitted to the ICU with severe acute exacerbations of chronic obstructive pulmonary disease (COPD) with or without pneumonia?

Background: Studies have demonstrated PCT-based strategies can safely reduce antibiotic use in patients without severe lower respiratory tract infections, community-acquired pneumonia, or acute exacerbations of COPD. The data on safety of PCT-based strategies in critically ill patients is limited.

Study design: Prospective, multicenter, randomized, controlled trial.

Setting: ICUs of 11 hospitals in France, including 7 tertiary care hospitals.

Synopsis: In this study 302 patients admitted to the ICU with severe exacerbations of COPD with or without pneumonia were randomly assigned to groups with antibiotic therapy guided by a PCT protocol or standard guidelines. Overall, the study failed to demonstrate noninferiority of a PCT-based strategy to reduce exposure to antibiotics. Specifically, the adjusted difference in mortality was 6.6% higher (90% confidence interval, 0.3%-13.5%) in the intervention group with no significant reduction in antibiotic exposure.

One limitation of this study was that it was an open trial in which clinicians were aware that their management was being observed.

Bottom line: A PCT-based algorithm was not effective in safely reducing antibiotic exposure in patients with acute exacerbations of COPD admitted to the ICU.

Citation: Daubin C et al. Procalcitonin algorithm to guide initial antibiotic therapy in acute exacerbations of COPD admitted to the ICU: A randomized multicenter study. Intensive Care Med. 2018 Apr;44(4):428-37.

Dr. Agith is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Clinical question: Can a procalcitonin (PCT)–guided strategy safely reduce antibiotic exposure in patients admitted to the ICU with severe acute exacerbations of chronic obstructive pulmonary disease (COPD) with or without pneumonia?

Background: Studies have demonstrated PCT-based strategies can safely reduce antibiotic use in patients without severe lower respiratory tract infections, community-acquired pneumonia, or acute exacerbations of COPD. The data on safety of PCT-based strategies in critically ill patients is limited.

Study design: Prospective, multicenter, randomized, controlled trial.

Setting: ICUs of 11 hospitals in France, including 7 tertiary care hospitals.

Synopsis: In this study 302 patients admitted to the ICU with severe exacerbations of COPD with or without pneumonia were randomly assigned to groups with antibiotic therapy guided by a PCT protocol or standard guidelines. Overall, the study failed to demonstrate noninferiority of a PCT-based strategy to reduce exposure to antibiotics. Specifically, the adjusted difference in mortality was 6.6% higher (90% confidence interval, 0.3%-13.5%) in the intervention group with no significant reduction in antibiotic exposure.

One limitation of this study was that it was an open trial in which clinicians were aware that their management was being observed.

Bottom line: A PCT-based algorithm was not effective in safely reducing antibiotic exposure in patients with acute exacerbations of COPD admitted to the ICU.

Citation: Daubin C et al. Procalcitonin algorithm to guide initial antibiotic therapy in acute exacerbations of COPD admitted to the ICU: A randomized multicenter study. Intensive Care Med. 2018 Apr;44(4):428-37.

Dr. Agith is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Clinical question: Can a procalcitonin (PCT)–guided strategy safely reduce antibiotic exposure in patients admitted to the ICU with severe acute exacerbations of chronic obstructive pulmonary disease (COPD) with or without pneumonia?

Background: Studies have demonstrated PCT-based strategies can safely reduce antibiotic use in patients without severe lower respiratory tract infections, community-acquired pneumonia, or acute exacerbations of COPD. The data on safety of PCT-based strategies in critically ill patients is limited.

Study design: Prospective, multicenter, randomized, controlled trial.

Setting: ICUs of 11 hospitals in France, including 7 tertiary care hospitals.

Synopsis: In this study 302 patients admitted to the ICU with severe exacerbations of COPD with or without pneumonia were randomly assigned to groups with antibiotic therapy guided by a PCT protocol or standard guidelines. Overall, the study failed to demonstrate noninferiority of a PCT-based strategy to reduce exposure to antibiotics. Specifically, the adjusted difference in mortality was 6.6% higher (90% confidence interval, 0.3%-13.5%) in the intervention group with no significant reduction in antibiotic exposure.

One limitation of this study was that it was an open trial in which clinicians were aware that their management was being observed.

Bottom line: A PCT-based algorithm was not effective in safely reducing antibiotic exposure in patients with acute exacerbations of COPD admitted to the ICU.

Citation: Daubin C et al. Procalcitonin algorithm to guide initial antibiotic therapy in acute exacerbations of COPD admitted to the ICU: A randomized multicenter study. Intensive Care Med. 2018 Apr;44(4):428-37.

Dr. Agith is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

The Food and Drug Administration has approved omadacycline (Nuzyra), a tetracycline antibiotic, for treating community-acquired bacterial pneumonia (CABP) and acute bacterial skin and skin structure infections (ABSSSI) in adults, the manufacturer, Paratek, announced in a press release.

The company expects that omadacycline will be available in the first quarter of 2019. Administered once-daily in either oral or IV formulations, the antibiotic was effective and well tolerated across multiple trials, which altogether included almost 2,000 patients, according to Paratek. As part of the approval, the company has agreed to conduct postmarketing studies, specifically, more studies in CABP and in pediatric populations. “To reduce the development of drug-resistant bacteria and maintain the effectiveness of Nuzyra and other antibacterial drugs, Nuzyra should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria,” according to a statement in the indications section of the prescribing information.

Omadacycline is contraindicated for patients with a known hypersensitivity to the drug or any members of the tetracycline class of antibacterial drugs; hypersensitivity reactions have been observed, so use should be discontinued if one is suspected. Use of this drug during later stages of pregnancy can lead to irreversible discoloration of the infant’s teeth and inhibition of bone growth; it should also not be used during breastfeeding.

Because omadacycline is structurally similar to tetracycline class drugs, some adverse reactions to those drugs may be seen with this one, such as photosensitivity, pseudotumor cerebri, and antianabolic action. Adverse reactions known to have an association with omadacycline include nausea, vomiting, hypertension, insomnia, diarrhea, constipation, and increases of alanine aminotransferase, aspartate aminotransferase, and/or gamma-glutamyl transferase.

Drug interactions may occur with anticoagulants, so dosage of those drugs may need to be reduced while treating with omadacycline. Antacids also are believed to have a drug interaction – specifically, impairing absorption of omadacycline

[email protected]

The Food and Drug Administration has approved omadacycline (Nuzyra), a tetracycline antibiotic, for treating community-acquired bacterial pneumonia (CABP) and acute bacterial skin and skin structure infections (ABSSSI) in adults, the manufacturer, Paratek, announced in a press release.

The company expects that omadacycline will be available in the first quarter of 2019. Administered once-daily in either oral or IV formulations, the antibiotic was effective and well tolerated across multiple trials, which altogether included almost 2,000 patients, according to Paratek. As part of the approval, the company has agreed to conduct postmarketing studies, specifically, more studies in CABP and in pediatric populations. “To reduce the development of drug-resistant bacteria and maintain the effectiveness of Nuzyra and other antibacterial drugs, Nuzyra should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria,” according to a statement in the indications section of the prescribing information.

Omadacycline is contraindicated for patients with a known hypersensitivity to the drug or any members of the tetracycline class of antibacterial drugs; hypersensitivity reactions have been observed, so use should be discontinued if one is suspected. Use of this drug during later stages of pregnancy can lead to irreversible discoloration of the infant’s teeth and inhibition of bone growth; it should also not be used during breastfeeding.

Because omadacycline is structurally similar to tetracycline class drugs, some adverse reactions to those drugs may be seen with this one, such as photosensitivity, pseudotumor cerebri, and antianabolic action. Adverse reactions known to have an association with omadacycline include nausea, vomiting, hypertension, insomnia, diarrhea, constipation, and increases of alanine aminotransferase, aspartate aminotransferase, and/or gamma-glutamyl transferase.

Drug interactions may occur with anticoagulants, so dosage of those drugs may need to be reduced while treating with omadacycline. Antacids also are believed to have a drug interaction – specifically, impairing absorption of omadacycline

[email protected]

The Food and Drug Administration has approved omadacycline (Nuzyra), a tetracycline antibiotic, for treating community-acquired bacterial pneumonia (CABP) and acute bacterial skin and skin structure infections (ABSSSI) in adults, the manufacturer, Paratek, announced in a press release.

The company expects that omadacycline will be available in the first quarter of 2019. Administered once-daily in either oral or IV formulations, the antibiotic was effective and well tolerated across multiple trials, which altogether included almost 2,000 patients, according to Paratek. As part of the approval, the company has agreed to conduct postmarketing studies, specifically, more studies in CABP and in pediatric populations. “To reduce the development of drug-resistant bacteria and maintain the effectiveness of Nuzyra and other antibacterial drugs, Nuzyra should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria,” according to a statement in the indications section of the prescribing information.

Omadacycline is contraindicated for patients with a known hypersensitivity to the drug or any members of the tetracycline class of antibacterial drugs; hypersensitivity reactions have been observed, so use should be discontinued if one is suspected. Use of this drug during later stages of pregnancy can lead to irreversible discoloration of the infant’s teeth and inhibition of bone growth; it should also not be used during breastfeeding.

Because omadacycline is structurally similar to tetracycline class drugs, some adverse reactions to those drugs may be seen with this one, such as photosensitivity, pseudotumor cerebri, and antianabolic action. Adverse reactions known to have an association with omadacycline include nausea, vomiting, hypertension, insomnia, diarrhea, constipation, and increases of alanine aminotransferase, aspartate aminotransferase, and/or gamma-glutamyl transferase.

Drug interactions may occur with anticoagulants, so dosage of those drugs may need to be reduced while treating with omadacycline. Antacids also are believed to have a drug interaction – specifically, impairing absorption of omadacycline

[email protected]

Clinical question: Do preoperative hemoglobin A_1c (HbA_1c) and perioperative glucose predict outcomes in patients undergoing noncardiac and cardiac surgeries?

Background: Hyperglycemia in the perioperative period has been associated with infection, delayed wound healing, and postoperative mortality. Studies have investigated the effects of HbA_1c or hyperglycemia on postoperative outcomes, but none have been performed to assess the effect of one while controlling for the other.

Study design: Retrospective analysis.

Setting: Single-center, Duke University Health System.

Synopsis: Using a database of electronic health records at Duke University Health System, Durham, N.C., investigators reviewed 13,077 surgeries (6,684 noncardiac and 6,393 cardiac) to determine the association of preoperative HbA_1c with perioperative glucose and 30-day mortality. For noncardiac surgery, increased average perioperative glucose was associated with increased mortality (P = .04). In cardiac surgery both low and high average glucose was associated with increased mortality (P = .001). By contrast, HbA_1c was not a significant predictor of postoperative mortality in cardiac surgery (P = .08), and in noncardiac surgery, HbA_1C was negatively associated with 30-day mortality (P = .01). Overall, perioperative glucose was predictive of 30-day mortality, but HbA_1c was not associated with 30-day mortality after researchers controlled for glucose.

Because the study is retrospective, no causal relationship can be established. Hospitalists involved in perioperative care should aim for optimization of glucose control regardless of preoperative HbA_1c.

Bottom line: Perioperative glucose is related to surgical outcomes, but HbA_1c is a less useful indicator of 30-day postoperative mortality.

Citation: Van den Boom W et al. Effect of A1C and glucose on postoperative mortality in noncardiac and cardiac surgeries. Diabetes Care. 2018 Feb;41:782-8.

Clinical question: Do preoperative hemoglobin A_1c (HbA_1c) and perioperative glucose predict outcomes in patients undergoing noncardiac and cardiac surgeries?

Background: Hyperglycemia in the perioperative period has been associated with infection, delayed wound healing, and postoperative mortality. Studies have investigated the effects of HbA_1c or hyperglycemia on postoperative outcomes, but none have been performed to assess the effect of one while controlling for the other.

Study design: Retrospective analysis.

Setting: Single-center, Duke University Health System.

Synopsis: Using a database of electronic health records at Duke University Health System, Durham, N.C., investigators reviewed 13,077 surgeries (6,684 noncardiac and 6,393 cardiac) to determine the association of preoperative HbA_1c with perioperative glucose and 30-day mortality. For noncardiac surgery, increased average perioperative glucose was associated with increased mortality (P = .04). In cardiac surgery both low and high average glucose was associated with increased mortality (P = .001). By contrast, HbA_1c was not a significant predictor of postoperative mortality in cardiac surgery (P = .08), and in noncardiac surgery, HbA_1C was negatively associated with 30-day mortality (P = .01). Overall, perioperative glucose was predictive of 30-day mortality, but HbA_1c was not associated with 30-day mortality after researchers controlled for glucose.

Because the study is retrospective, no causal relationship can be established. Hospitalists involved in perioperative care should aim for optimization of glucose control regardless of preoperative HbA_1c.

Bottom line: Perioperative glucose is related to surgical outcomes, but HbA_1c is a less useful indicator of 30-day postoperative mortality.

Citation: Van den Boom W et al. Effect of A1C and glucose on postoperative mortality in noncardiac and cardiac surgeries. Diabetes Care. 2018 Feb;41:782-8.

Clinical question: Do preoperative hemoglobin A_1c (HbA_1c) and perioperative glucose predict outcomes in patients undergoing noncardiac and cardiac surgeries?

Background: Hyperglycemia in the perioperative period has been associated with infection, delayed wound healing, and postoperative mortality. Studies have investigated the effects of HbA_1c or hyperglycemia on postoperative outcomes, but none have been performed to assess the effect of one while controlling for the other.

Study design: Retrospective analysis.

Setting: Single-center, Duke University Health System.

Synopsis: Using a database of electronic health records at Duke University Health System, Durham, N.C., investigators reviewed 13,077 surgeries (6,684 noncardiac and 6,393 cardiac) to determine the association of preoperative HbA_1c with perioperative glucose and 30-day mortality. For noncardiac surgery, increased average perioperative glucose was associated with increased mortality (P = .04). In cardiac surgery both low and high average glucose was associated with increased mortality (P = .001). By contrast, HbA_1c was not a significant predictor of postoperative mortality in cardiac surgery (P = .08), and in noncardiac surgery, HbA_1C was negatively associated with 30-day mortality (P = .01). Overall, perioperative glucose was predictive of 30-day mortality, but HbA_1c was not associated with 30-day mortality after researchers controlled for glucose.

Because the study is retrospective, no causal relationship can be established. Hospitalists involved in perioperative care should aim for optimization of glucose control regardless of preoperative HbA_1c.

Bottom line: Perioperative glucose is related to surgical outcomes, but HbA_1c is a less useful indicator of 30-day postoperative mortality.

Citation: Van den Boom W et al. Effect of A1C and glucose on postoperative mortality in noncardiac and cardiac surgeries. Diabetes Care. 2018 Feb;41:782-8.

Clinical question: Can one predict whether nonoperative management of spinal epidural abscesses will fail?

Background: Even though spinal epidural abscesses have a low incidence and nonspecific presentation, a delay in treatment can lead to significant morbidity. Previously, operative management was the preferred treatment; however, improvements in imaging and timing of diagnosis have led to an increased interest in nonoperative management. Few studies have identified possible predictors of failure for nonoperative management, and no algorithm exists for weighing the different possible predictors with the outcome of nonoperative management failure.

Study design: Retrospective cohort study.

Setting: A Massachusetts hospital system with two tertiary academic medical centers and three regional community hospitals.

Synopsis: The study evaluated 1,053 patients admitted with a spinal epidural abscess during 1993-2016. Of these, 432 patients were managed nonoperatively, and 367 were included in the analysis. Failure of nonoperative management occurred in 99 patients (27%). These patients were compared with 266 patients with successful nonoperative management with more than 60 days of follow-up. Six independent factors were associated with failure of nonoperative management including motor deficit at presentation (odds ratio, 7.85), pathological or compression fractures (OR, 6.12), active malignancy (OR, 3.32), diabetes (OR, 2.92), sensory changes at presentation (3.48), and location of the abscess dorsal to the thecal sac (OR, 0.29). Subsequently, a clinical algorithm was created to predict the likelihood of failure of nonoperative management.

Because of its retrospective design, the study was unable to assess the efficacy of surgery versus nonoperative management.
 

Bottom line: Specific measures of general health, neurologic status at presentation, and anatomical data of a patient with a spinal epidural abscess have led to the development of a clinical algorithm to determine the risk of failure in nonoperative management of spinal epidural abscesses.

Citation: Shah AA et al. Nonoperative management of spinal epidural abscess: Development of a predictive algorithm for failure. J Bone Joint Surg Am. 2018;100(7):546-55.

Dr. Tsien is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Clinical question: Can one predict whether nonoperative management of spinal epidural abscesses will fail?

Background: Even though spinal epidural abscesses have a low incidence and nonspecific presentation, a delay in treatment can lead to significant morbidity. Previously, operative management was the preferred treatment; however, improvements in imaging and timing of diagnosis have led to an increased interest in nonoperative management. Few studies have identified possible predictors of failure for nonoperative management, and no algorithm exists for weighing the different possible predictors with the outcome of nonoperative management failure.

Study design: Retrospective cohort study.

Setting: A Massachusetts hospital system with two tertiary academic medical centers and three regional community hospitals.

Synopsis: The study evaluated 1,053 patients admitted with a spinal epidural abscess during 1993-2016. Of these, 432 patients were managed nonoperatively, and 367 were included in the analysis. Failure of nonoperative management occurred in 99 patients (27%). These patients were compared with 266 patients with successful nonoperative management with more than 60 days of follow-up. Six independent factors were associated with failure of nonoperative management including motor deficit at presentation (odds ratio, 7.85), pathological or compression fractures (OR, 6.12), active malignancy (OR, 3.32), diabetes (OR, 2.92), sensory changes at presentation (3.48), and location of the abscess dorsal to the thecal sac (OR, 0.29). Subsequently, a clinical algorithm was created to predict the likelihood of failure of nonoperative management.

Because of its retrospective design, the study was unable to assess the efficacy of surgery versus nonoperative management.
 

Bottom line: Specific measures of general health, neurologic status at presentation, and anatomical data of a patient with a spinal epidural abscess have led to the development of a clinical algorithm to determine the risk of failure in nonoperative management of spinal epidural abscesses.

Citation: Shah AA et al. Nonoperative management of spinal epidural abscess: Development of a predictive algorithm for failure. J Bone Joint Surg Am. 2018;100(7):546-55.

Dr. Tsien is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Clinical question: Can one predict whether nonoperative management of spinal epidural abscesses will fail?

Background: Even though spinal epidural abscesses have a low incidence and nonspecific presentation, a delay in treatment can lead to significant morbidity. Previously, operative management was the preferred treatment; however, improvements in imaging and timing of diagnosis have led to an increased interest in nonoperative management. Few studies have identified possible predictors of failure for nonoperative management, and no algorithm exists for weighing the different possible predictors with the outcome of nonoperative management failure.

Study design: Retrospective cohort study.

Setting: A Massachusetts hospital system with two tertiary academic medical centers and three regional community hospitals.

Synopsis: The study evaluated 1,053 patients admitted with a spinal epidural abscess during 1993-2016. Of these, 432 patients were managed nonoperatively, and 367 were included in the analysis. Failure of nonoperative management occurred in 99 patients (27%). These patients were compared with 266 patients with successful nonoperative management with more than 60 days of follow-up. Six independent factors were associated with failure of nonoperative management including motor deficit at presentation (odds ratio, 7.85), pathological or compression fractures (OR, 6.12), active malignancy (OR, 3.32), diabetes (OR, 2.92), sensory changes at presentation (3.48), and location of the abscess dorsal to the thecal sac (OR, 0.29). Subsequently, a clinical algorithm was created to predict the likelihood of failure of nonoperative management.

Because of its retrospective design, the study was unable to assess the efficacy of surgery versus nonoperative management.
 

Bottom line: Specific measures of general health, neurologic status at presentation, and anatomical data of a patient with a spinal epidural abscess have led to the development of a clinical algorithm to determine the risk of failure in nonoperative management of spinal epidural abscesses.

Citation: Shah AA et al. Nonoperative management of spinal epidural abscess: Development of a predictive algorithm for failure. J Bone Joint Surg Am. 2018;100(7):546-55.

Dr. Tsien is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Clinical question: Does patient experience correlate with specific hospital care coordination and transition strategies, and if so, which strategies most strongly correlate with higher patient experience scores?

Background: Patient experience is an increasingly important measure in value-based payment programs. However, progress has been slow in improving patient experience, and little empirical data exist regarding which strategies are effective. Care transitions are critical times during a hospitalization, with many hospitals already implementing measures to improve the discharge process and prevent readmission of patients. It is not known whether those measures also influence patient experience scores, and if they do improve scores, which measures are most effective at doing so.

Study design: An analytic observational survey design.

Setting: Hospitals eligible for the Hospital Readmissions Reduction Program (HRRP) between June 2013 and December 2014.

Synopsis: A survey was developed and given to chief medical officers at 1,600 hospitals between June 2013 and December 2014; the survey assessed care coordination strategies employed by these institutions. 992 hospitals (62% response rate) were subsequently categorized as “low-strategy,” “mid-strategy,” or “high-strategy” hospitals. Patient satisfaction scores from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey in 2014 were correlated to the number of strategies and the specific strategies each hospital employed. In general, the higher-strategy hospitals had significantly higher HCAHPS survey scores than did low-strategy hospitals (+2.23 points; P less than .001). Specifically, creating and sharing a discharge summary prior to discharge (+1.43 points; P less than .001), using a discharge planner (+1.71 points; P less than .001), and calling patients 48 hours post discharge (+1.64 points; P less than .001) all resulted in overall higher hospital ratings by patients.
 

One limitation of this study is that no causal inference can be made between the specific strategies associated with higher HCAHPS scores and care coordination strategies.

Bottom line: Hospital-led care transition strategies with direct patient interactions led to higher patient satisfaction scores.

Citation: Figueroa JF et al. Hospital-level care coordination strategies associated with better patient experience. BMJ Qual Saf. 2018 Apr 4. doi: 10.1136/bmjqs-2017-007597.

Dr. Tsien is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Clinical question: Does patient experience correlate with specific hospital care coordination and transition strategies, and if so, which strategies most strongly correlate with higher patient experience scores?

Background: Patient experience is an increasingly important measure in value-based payment programs. However, progress has been slow in improving patient experience, and little empirical data exist regarding which strategies are effective. Care transitions are critical times during a hospitalization, with many hospitals already implementing measures to improve the discharge process and prevent readmission of patients. It is not known whether those measures also influence patient experience scores, and if they do improve scores, which measures are most effective at doing so.

Study design: An analytic observational survey design.

Setting: Hospitals eligible for the Hospital Readmissions Reduction Program (HRRP) between June 2013 and December 2014.

Synopsis: A survey was developed and given to chief medical officers at 1,600 hospitals between June 2013 and December 2014; the survey assessed care coordination strategies employed by these institutions. 992 hospitals (62% response rate) were subsequently categorized as “low-strategy,” “mid-strategy,” or “high-strategy” hospitals. Patient satisfaction scores from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey in 2014 were correlated to the number of strategies and the specific strategies each hospital employed. In general, the higher-strategy hospitals had significantly higher HCAHPS survey scores than did low-strategy hospitals (+2.23 points; P less than .001). Specifically, creating and sharing a discharge summary prior to discharge (+1.43 points; P less than .001), using a discharge planner (+1.71 points; P less than .001), and calling patients 48 hours post discharge (+1.64 points; P less than .001) all resulted in overall higher hospital ratings by patients.
 

One limitation of this study is that no causal inference can be made between the specific strategies associated with higher HCAHPS scores and care coordination strategies.

Bottom line: Hospital-led care transition strategies with direct patient interactions led to higher patient satisfaction scores.

Citation: Figueroa JF et al. Hospital-level care coordination strategies associated with better patient experience. BMJ Qual Saf. 2018 Apr 4. doi: 10.1136/bmjqs-2017-007597.

Dr. Tsien is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Clinical question: Does patient experience correlate with specific hospital care coordination and transition strategies, and if so, which strategies most strongly correlate with higher patient experience scores?

Background: Patient experience is an increasingly important measure in value-based payment programs. However, progress has been slow in improving patient experience, and little empirical data exist regarding which strategies are effective. Care transitions are critical times during a hospitalization, with many hospitals already implementing measures to improve the discharge process and prevent readmission of patients. It is not known whether those measures also influence patient experience scores, and if they do improve scores, which measures are most effective at doing so.

Study design: An analytic observational survey design.

Setting: Hospitals eligible for the Hospital Readmissions Reduction Program (HRRP) between June 2013 and December 2014.

Synopsis: A survey was developed and given to chief medical officers at 1,600 hospitals between June 2013 and December 2014; the survey assessed care coordination strategies employed by these institutions. 992 hospitals (62% response rate) were subsequently categorized as “low-strategy,” “mid-strategy,” or “high-strategy” hospitals. Patient satisfaction scores from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey in 2014 were correlated to the number of strategies and the specific strategies each hospital employed. In general, the higher-strategy hospitals had significantly higher HCAHPS survey scores than did low-strategy hospitals (+2.23 points; P less than .001). Specifically, creating and sharing a discharge summary prior to discharge (+1.43 points; P less than .001), using a discharge planner (+1.71 points; P less than .001), and calling patients 48 hours post discharge (+1.64 points; P less than .001) all resulted in overall higher hospital ratings by patients.
 

One limitation of this study is that no causal inference can be made between the specific strategies associated with higher HCAHPS scores and care coordination strategies.

Bottom line: Hospital-led care transition strategies with direct patient interactions led to higher patient satisfaction scores.

Citation: Figueroa JF et al. Hospital-level care coordination strategies associated with better patient experience. BMJ Qual Saf. 2018 Apr 4. doi: 10.1136/bmjqs-2017-007597.

Dr. Tsien is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

CHICAGO – Patients in the SPRINT trial were less likely to meet the intensive treatment goal – systolic blood pressure below 120 mm Hg – if they were taking five or more medications a day, according to a post hoc analysis.

M. Alexander Otto/MDedge News

“Five or more medications” meant total drug burden, both for hypertension and comorbidities. “When you are treating a patient for hypertension, you care about blood pressure, but you also need to care about” what else they are on, and their total drug burden, “because it affects their ability to get to their blood pressure goal, especially if you’re targeting intensive control,” said lead investigator Catherine Derington, PharmD, a postdoctoral fellow at the University of Colorado, Aurora.

Good old-fashioned exercise and weight loss remain potent non–pill options, she noted at the joint scientific sessions of AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.

M. Alexander Otto/MDedge News

The take-home message is to use more combination drugs for hypertension “to get patients on fewer pills.” Also, “eliminate drugs [patients] don’t need,” said SPRINT investigator William C. Cushman, MD, professor of medicine and physiology at the University of Tennessee, Memphis, when asked what he thought of the new findings.

SPRINT [Systolic Blood Pressure Intervention Trial] found that targeting systolic blood pressures below 120 mm Hg, as compared with less than 140 mm Hg, led to lower rates of MI, stroke, heart failure, and death from any cause.

Medication burden had no effect on patients in the 140 mm Hg group; they achieved a mean systolic blood pressure (SBP) of 136 mm Hg at 1 year, whether they were on fewer than five drugs a day or more. Hitting that target took an average of 1.8 hypertension medications.

Reaching 120 mm Hg generally took one extra drug (an average of 2.8), and the overall pill burden did matter; 2,463 patients in the intensive arm on fewer than five medications dropped their mean SBP 20 mm Hg at one year, while 1,698 taking more than five had a 15–mm Hg reduction. The group with the lower pill burden had a mean SBP of 120.6 mm Hg and those taking five or more had a mean SBP of 122.5 mm Hg. It’s a small difference but likely important.

Comorbidities in SPRINT included kidney and cardiovascular disease, among others, but the trial excluded patients with diabetes. Many patients were on statins and aspirin.

Pharmacy review is especially a good idea in the elderly.

Patients on five or more medications had higher rates of significant adverse events in the post hoc analysis (about 50% versus about 30%), including hypotension, syncope, electrolyte abnormalities, and acute kidney injury, regardless if they were in the 120–mm Hg or 140–mm Hg group.

About 45% in the intensive arm reported high adherence (Morisky Medication Adherence Scale-8 score greater than 8 at 12 months); medication burden made no difference. Oddly, in the standard-treatment arm, more patients on five or more drugs reported high adherence, 44.5% versus 38.1% among patients taking fewer,

The post hoc analysis was based on pill bottle review at baseline. Medication count did not affect hypertension treatment satisfaction, which was about 84% in the intensive and 77% in the standard arm.

There was no industry funding for the work. Dr. Derington didn’t have any disclosures.
 

[email protected]

CHICAGO – Patients in the SPRINT trial were less likely to meet the intensive treatment goal – systolic blood pressure below 120 mm Hg – if they were taking five or more medications a day, according to a post hoc analysis.

M. Alexander Otto/MDedge News

“Five or more medications” meant total drug burden, both for hypertension and comorbidities. “When you are treating a patient for hypertension, you care about blood pressure, but you also need to care about” what else they are on, and their total drug burden, “because it affects their ability to get to their blood pressure goal, especially if you’re targeting intensive control,” said lead investigator Catherine Derington, PharmD, a postdoctoral fellow at the University of Colorado, Aurora.

Good old-fashioned exercise and weight loss remain potent non–pill options, she noted at the joint scientific sessions of AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.

M. Alexander Otto/MDedge News

The take-home message is to use more combination drugs for hypertension “to get patients on fewer pills.” Also, “eliminate drugs [patients] don’t need,” said SPRINT investigator William C. Cushman, MD, professor of medicine and physiology at the University of Tennessee, Memphis, when asked what he thought of the new findings.

SPRINT [Systolic Blood Pressure Intervention Trial] found that targeting systolic blood pressures below 120 mm Hg, as compared with less than 140 mm Hg, led to lower rates of MI, stroke, heart failure, and death from any cause.

Medication burden had no effect on patients in the 140 mm Hg group; they achieved a mean systolic blood pressure (SBP) of 136 mm Hg at 1 year, whether they were on fewer than five drugs a day or more. Hitting that target took an average of 1.8 hypertension medications.

Reaching 120 mm Hg generally took one extra drug (an average of 2.8), and the overall pill burden did matter; 2,463 patients in the intensive arm on fewer than five medications dropped their mean SBP 20 mm Hg at one year, while 1,698 taking more than five had a 15–mm Hg reduction. The group with the lower pill burden had a mean SBP of 120.6 mm Hg and those taking five or more had a mean SBP of 122.5 mm Hg. It’s a small difference but likely important.

Comorbidities in SPRINT included kidney and cardiovascular disease, among others, but the trial excluded patients with diabetes. Many patients were on statins and aspirin.

Pharmacy review is especially a good idea in the elderly.

Patients on five or more medications had higher rates of significant adverse events in the post hoc analysis (about 50% versus about 30%), including hypotension, syncope, electrolyte abnormalities, and acute kidney injury, regardless if they were in the 120–mm Hg or 140–mm Hg group.

About 45% in the intensive arm reported high adherence (Morisky Medication Adherence Scale-8 score greater than 8 at 12 months); medication burden made no difference. Oddly, in the standard-treatment arm, more patients on five or more drugs reported high adherence, 44.5% versus 38.1% among patients taking fewer,

The post hoc analysis was based on pill bottle review at baseline. Medication count did not affect hypertension treatment satisfaction, which was about 84% in the intensive and 77% in the standard arm.

There was no industry funding for the work. Dr. Derington didn’t have any disclosures.
 

[email protected]

CHICAGO – Patients in the SPRINT trial were less likely to meet the intensive treatment goal – systolic blood pressure below 120 mm Hg – if they were taking five or more medications a day, according to a post hoc analysis.

M. Alexander Otto/MDedge News

“Five or more medications” meant total drug burden, both for hypertension and comorbidities. “When you are treating a patient for hypertension, you care about blood pressure, but you also need to care about” what else they are on, and their total drug burden, “because it affects their ability to get to their blood pressure goal, especially if you’re targeting intensive control,” said lead investigator Catherine Derington, PharmD, a postdoctoral fellow at the University of Colorado, Aurora.

Good old-fashioned exercise and weight loss remain potent non–pill options, she noted at the joint scientific sessions of AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.

M. Alexander Otto/MDedge News

The take-home message is to use more combination drugs for hypertension “to get patients on fewer pills.” Also, “eliminate drugs [patients] don’t need,” said SPRINT investigator William C. Cushman, MD, professor of medicine and physiology at the University of Tennessee, Memphis, when asked what he thought of the new findings.

SPRINT [Systolic Blood Pressure Intervention Trial] found that targeting systolic blood pressures below 120 mm Hg, as compared with less than 140 mm Hg, led to lower rates of MI, stroke, heart failure, and death from any cause.

Medication burden had no effect on patients in the 140 mm Hg group; they achieved a mean systolic blood pressure (SBP) of 136 mm Hg at 1 year, whether they were on fewer than five drugs a day or more. Hitting that target took an average of 1.8 hypertension medications.

Reaching 120 mm Hg generally took one extra drug (an average of 2.8), and the overall pill burden did matter; 2,463 patients in the intensive arm on fewer than five medications dropped their mean SBP 20 mm Hg at one year, while 1,698 taking more than five had a 15–mm Hg reduction. The group with the lower pill burden had a mean SBP of 120.6 mm Hg and those taking five or more had a mean SBP of 122.5 mm Hg. It’s a small difference but likely important.

Comorbidities in SPRINT included kidney and cardiovascular disease, among others, but the trial excluded patients with diabetes. Many patients were on statins and aspirin.

Pharmacy review is especially a good idea in the elderly.

Patients on five or more medications had higher rates of significant adverse events in the post hoc analysis (about 50% versus about 30%), including hypotension, syncope, electrolyte abnormalities, and acute kidney injury, regardless if they were in the 120–mm Hg or 140–mm Hg group.

About 45% in the intensive arm reported high adherence (Morisky Medication Adherence Scale-8 score greater than 8 at 12 months); medication burden made no difference. Oddly, in the standard-treatment arm, more patients on five or more drugs reported high adherence, 44.5% versus 38.1% among patients taking fewer,

The post hoc analysis was based on pill bottle review at baseline. Medication count did not affect hypertension treatment satisfaction, which was about 84% in the intensive and 77% in the standard arm.

There was no industry funding for the work. Dr. Derington didn’t have any disclosures.
 

[email protected]

SAN DIEGO – For patients with severe rib injuries, low-dose ketamine infusions kept pain under control while reducing opioid consumption.

Michele G Sullivan/MDedge News

The anesthetic didn’t make much difference in pain control or opioid use overall in a randomized study of 93 patients with thoracic injury Nathan Kugler, MD, said at the annual meeting of the American Association for the Surgery of Trauma. But among severely injured patients, it cut the opioid mean equivalency dose by about 164 mg over the 48-hour infusion and by 328 mg over a mean hospital stay while maintaining pain control, said Dr. Kugler, a surgical resident at the Medical College of Wisconsin, Milwaukee.

“With increasing focus on multimodal pain strategies, opioid-based regimens continue to be the backbone of pain control,” he said. “We have used ketamine effectively for failure of maximum therapy and demonstrated an opioid-sparing effect.” This new research shows that the drug can be an effective adjunct for acute pain control for severely injured patients in the emergency setting.

The study recruited 93 patients with thoracic injury; they had a mean of six broken ribs, mostly caused by motor vehicle accidents. Most of the patients were male (75%), and their mean age was 46 years. The mean Injury Severity Score was about 15; about 30% had flail chest.

All patients received a standardized acute pain medication regime comprising acetaminophen, nonsteroidal anti-inflammatories, methocarbamol (Robaxin), and intravenous opioids. Regional therapies included rib block with an epidural catheter. In addition, they were randomized to placebo infusions or to 48 hours of IV ketamine at 2.5 mcg/kg per minute. “To put this in perspective, for a 70-kg patient, that is a mean of 10.5 mg/hour,” Dr. Kugler said.

The primary endpoint was a reduction of at least 2 points on an 11-point pain scale. Secondary endpoints included opioid use in oral morphine equivalents (OME); respiratory complications; and psychoactive events. The primary outcome was assessed with an area under the curve model.

In the overall group, there was no significant between-group difference in pain score. Nor were there differences in the total OME at 12-24 hours (184 mg ketamine vs. 230 mg placebo), or at 48 hours (86 vs. 113 mg).

Dr. Kugler also looked at these outcomes in patients who had only rib fractures independent of other chest injury. He saw no significant differences in pain scores or OME at 24 or 48 hours.

However, significant differences did emerge in the group of severely injured patients with an Injury Severity Score of more than 15. There were no differences in pain scores at either time point. However, ketamine allowed patients to achieve the same level of pain control with significantly less opioid medication. The OME at 12-24 hours was 50.5 mg vs 94 mg. At 24-48 hours, it was 87 mg vs. 64 mg.

This worked out to a mean OME savings of 148 mg over a patient’s entire hospitalization.

“We saw a very nice separation of opioid consumption that began early and continued to separate over the 48-hour infusion and even after it was discontinued,” Dr. Kugler said.

This benefit was achieved without any additional adverse events, he added. There were no significant differences in confusion; epidural placement; length of stay; respiratory event, sedation, hallucinations, delusions or disturbing dreams; or unplanned transfers to the ICU.

Dr. Kugler disclosed that he and primary investigator Thomas Carver, MD, also of the Medical College of Wisconsin, Milwaukee, are both paid consultants for InnoVital Systems.

[email protected]

SOURCE: Carver T et al. AAST 2018, Oral abstract 2

SAN DIEGO – For patients with severe rib injuries, low-dose ketamine infusions kept pain under control while reducing opioid consumption.

Michele G Sullivan/MDedge News

The anesthetic didn’t make much difference in pain control or opioid use overall in a randomized study of 93 patients with thoracic injury Nathan Kugler, MD, said at the annual meeting of the American Association for the Surgery of Trauma. But among severely injured patients, it cut the opioid mean equivalency dose by about 164 mg over the 48-hour infusion and by 328 mg over a mean hospital stay while maintaining pain control, said Dr. Kugler, a surgical resident at the Medical College of Wisconsin, Milwaukee.

“With increasing focus on multimodal pain strategies, opioid-based regimens continue to be the backbone of pain control,” he said. “We have used ketamine effectively for failure of maximum therapy and demonstrated an opioid-sparing effect.” This new research shows that the drug can be an effective adjunct for acute pain control for severely injured patients in the emergency setting.

The study recruited 93 patients with thoracic injury; they had a mean of six broken ribs, mostly caused by motor vehicle accidents. Most of the patients were male (75%), and their mean age was 46 years. The mean Injury Severity Score was about 15; about 30% had flail chest.

All patients received a standardized acute pain medication regime comprising acetaminophen, nonsteroidal anti-inflammatories, methocarbamol (Robaxin), and intravenous opioids. Regional therapies included rib block with an epidural catheter. In addition, they were randomized to placebo infusions or to 48 hours of IV ketamine at 2.5 mcg/kg per minute. “To put this in perspective, for a 70-kg patient, that is a mean of 10.5 mg/hour,” Dr. Kugler said.

The primary endpoint was a reduction of at least 2 points on an 11-point pain scale. Secondary endpoints included opioid use in oral morphine equivalents (OME); respiratory complications; and psychoactive events. The primary outcome was assessed with an area under the curve model.

In the overall group, there was no significant between-group difference in pain score. Nor were there differences in the total OME at 12-24 hours (184 mg ketamine vs. 230 mg placebo), or at 48 hours (86 vs. 113 mg).

Dr. Kugler also looked at these outcomes in patients who had only rib fractures independent of other chest injury. He saw no significant differences in pain scores or OME at 24 or 48 hours.

However, significant differences did emerge in the group of severely injured patients with an Injury Severity Score of more than 15. There were no differences in pain scores at either time point. However, ketamine allowed patients to achieve the same level of pain control with significantly less opioid medication. The OME at 12-24 hours was 50.5 mg vs 94 mg. At 24-48 hours, it was 87 mg vs. 64 mg.

This worked out to a mean OME savings of 148 mg over a patient’s entire hospitalization.

“We saw a very nice separation of opioid consumption that began early and continued to separate over the 48-hour infusion and even after it was discontinued,” Dr. Kugler said.

This benefit was achieved without any additional adverse events, he added. There were no significant differences in confusion; epidural placement; length of stay; respiratory event, sedation, hallucinations, delusions or disturbing dreams; or unplanned transfers to the ICU.

Dr. Kugler disclosed that he and primary investigator Thomas Carver, MD, also of the Medical College of Wisconsin, Milwaukee, are both paid consultants for InnoVital Systems.

[email protected]

SOURCE: Carver T et al. AAST 2018, Oral abstract 2

SAN DIEGO – For patients with severe rib injuries, low-dose ketamine infusions kept pain under control while reducing opioid consumption.

Michele G Sullivan/MDedge News

The anesthetic didn’t make much difference in pain control or opioid use overall in a randomized study of 93 patients with thoracic injury Nathan Kugler, MD, said at the annual meeting of the American Association for the Surgery of Trauma. But among severely injured patients, it cut the opioid mean equivalency dose by about 164 mg over the 48-hour infusion and by 328 mg over a mean hospital stay while maintaining pain control, said Dr. Kugler, a surgical resident at the Medical College of Wisconsin, Milwaukee.

“With increasing focus on multimodal pain strategies, opioid-based regimens continue to be the backbone of pain control,” he said. “We have used ketamine effectively for failure of maximum therapy and demonstrated an opioid-sparing effect.” This new research shows that the drug can be an effective adjunct for acute pain control for severely injured patients in the emergency setting.

The study recruited 93 patients with thoracic injury; they had a mean of six broken ribs, mostly caused by motor vehicle accidents. Most of the patients were male (75%), and their mean age was 46 years. The mean Injury Severity Score was about 15; about 30% had flail chest.

All patients received a standardized acute pain medication regime comprising acetaminophen, nonsteroidal anti-inflammatories, methocarbamol (Robaxin), and intravenous opioids. Regional therapies included rib block with an epidural catheter. In addition, they were randomized to placebo infusions or to 48 hours of IV ketamine at 2.5 mcg/kg per minute. “To put this in perspective, for a 70-kg patient, that is a mean of 10.5 mg/hour,” Dr. Kugler said.

The primary endpoint was a reduction of at least 2 points on an 11-point pain scale. Secondary endpoints included opioid use in oral morphine equivalents (OME); respiratory complications; and psychoactive events. The primary outcome was assessed with an area under the curve model.

In the overall group, there was no significant between-group difference in pain score. Nor were there differences in the total OME at 12-24 hours (184 mg ketamine vs. 230 mg placebo), or at 48 hours (86 vs. 113 mg).

Dr. Kugler also looked at these outcomes in patients who had only rib fractures independent of other chest injury. He saw no significant differences in pain scores or OME at 24 or 48 hours.

However, significant differences did emerge in the group of severely injured patients with an Injury Severity Score of more than 15. There were no differences in pain scores at either time point. However, ketamine allowed patients to achieve the same level of pain control with significantly less opioid medication. The OME at 12-24 hours was 50.5 mg vs 94 mg. At 24-48 hours, it was 87 mg vs. 64 mg.

This worked out to a mean OME savings of 148 mg over a patient’s entire hospitalization.

“We saw a very nice separation of opioid consumption that began early and continued to separate over the 48-hour infusion and even after it was discontinued,” Dr. Kugler said.

This benefit was achieved without any additional adverse events, he added. There were no significant differences in confusion; epidural placement; length of stay; respiratory event, sedation, hallucinations, delusions or disturbing dreams; or unplanned transfers to the ICU.

Dr. Kugler disclosed that he and primary investigator Thomas Carver, MD, also of the Medical College of Wisconsin, Milwaukee, are both paid consultants for InnoVital Systems.

[email protected]

SOURCE: Carver T et al. AAST 2018, Oral abstract 2

Background: Health care costs are on the rise, and previous studies have found that PCC can reduce hospital costs. Timing of consultation and allocation of palliative care intervention to a certain population of patients may reveal a more significant cost reduction.

Only six samples were evaluated, and causation could not be established because all samples had observational designs. There also was potential interpretation bias because the private investigator for each of the samples contributed to interpretation of the data and participated as an author. Overall evaluation of the economic value of PCC in this study was limited because analysis was focused to a single index hospital admission rather than including additional hospitalizations and outpatient costs.

Bottom line: Acute care hospitals might reduce hospital costs by increasing resources to allow palliative care consultations in patients with serious illnesses.

Citation: May P et al. Economics of palliative care for hospitalized adults with serious illness. JAMA Intern Med. 2018;178(6):820-9.

Dr. Libot is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
 

Background: Health care costs are on the rise, and previous studies have found that PCC can reduce hospital costs. Timing of consultation and allocation of palliative care intervention to a certain population of patients may reveal a more significant cost reduction.

Only six samples were evaluated, and causation could not be established because all samples had observational designs. There also was potential interpretation bias because the private investigator for each of the samples contributed to interpretation of the data and participated as an author. Overall evaluation of the economic value of PCC in this study was limited because analysis was focused to a single index hospital admission rather than including additional hospitalizations and outpatient costs.

Bottom line: Acute care hospitals might reduce hospital costs by increasing resources to allow palliative care consultations in patients with serious illnesses.

Citation: May P et al. Economics of palliative care for hospitalized adults with serious illness. JAMA Intern Med. 2018;178(6):820-9.

Dr. Libot is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
 

Background: Health care costs are on the rise, and previous studies have found that PCC can reduce hospital costs. Timing of consultation and allocation of palliative care intervention to a certain population of patients may reveal a more significant cost reduction.

Only six samples were evaluated, and causation could not be established because all samples had observational designs. There also was potential interpretation bias because the private investigator for each of the samples contributed to interpretation of the data and participated as an author. Overall evaluation of the economic value of PCC in this study was limited because analysis was focused to a single index hospital admission rather than including additional hospitalizations and outpatient costs.

Bottom line: Acute care hospitals might reduce hospital costs by increasing resources to allow palliative care consultations in patients with serious illnesses.

Citation: May P et al. Economics of palliative care for hospitalized adults with serious illness. JAMA Intern Med. 2018;178(6):820-9.

Dr. Libot is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.